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A Case Study of Retrograde Amnesia

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A Case Study of Retrograde Amnesia BRAIN AND COGNITION 8, 3-20 (1988) Priming of Semantic Autobiographical Knowledge: A Case Study of Retrograde Amnesia ENDEL TULVING, DANIEL L. SCHACTER, DONALD R. MCLACHLAN, AND MORRIS MOSCOVITCH Unit for Memory Disorders, University of Toronto The case of a 36-year-old man who suffers dense retrograde and anterograde amnesia as a result of closed-head injury that caused extensive damage to his left frontal-parietal and right parieto-occipital lobes is described. Patient KC. has normal intelligence and relatively well-preserved perceptual, linguistic, short- term memory, and reasoning abilities. He possesses some fragmentary general knowledge about his autobiographical past, but he does not remember a single personal event or happening from any time of his life. He has some preserved expert knowledge related to the work he did for 3 years before the onset of amnesia, although he has no personal recollections from that period. Some features of K.C.‘s retrograde amnesia can be interpreted in terms of the distinction between episodic and semantic memory, and in terms of the distinction between episodic and semantic autobiographical knowledge. K.C.‘s semantic knowledge, but not his episodic knowledge, showed progressive improvement, or priming, in the course of the investigation. 0 1988 Academic Press. Inc. Much of the current knowledge and understanding of the amnesic syndrome is based on the study of anterograde impairment of memory function in brain-damaged patients. Less evidence is available about retrograde amnesia, that is, about retention of information acquired by the patients before the onset of amnesia. The present study makes a modest contribution to redressing the imbalance. It describes the case This research was supported by a Special Research Program Grant from the Connaught Fund, University of Toronto, and aided by grants from the Natural Sciences and Engineering Research Council of Canada to Endel Tulving and Daniel Schacter, and by grants from the Medical Research Council of Canada and Ontario Mental Health Foundation to Morris Moscovitch. We thank K.C. for his participation in the study, Rick Julian for referring him to us, Janine Law for experimental and logistical assistance, Donald Stuss for consultation and testing of K.C., and Stephen Gamett for the positron emission tomography and analysis. We are especially grateful to the members of K.C.‘s family, and to his friends, CA., R.A., and J.S. for providing us with the vital intelligence without which the study could not have been undertaken. Address correspondence and reprint requests to Endel Tulving, Department of Psychology, University of Toronto, Toronto, Ontario, Canada M5S IAI. 3 0278-2626188 $3.00 Copyright 0 1988 by Academic Press, Inc. All rights of reproduction in any form reserved. 4 TLJLVING ET AL. of a patient who, 5 years after an accident that caused massive closed- head injury, exhibits not only dense anterograde amnesia but also a severe impairment of autobiographical memory that covers his whole life. Traditionally, studies of retrograde amnesia have concentrated on the extent, severity, and temporal gradient of the impairment (e.g., Albert, Butters, & Levin, 1979; Butters & Albert, 1982; Marslen-Wilson & Teuber, 1975; Mayer-Gross, 1943; Russell & Nathan, 1946; Squire & Slater, 1975; Warrington & Sanders, 1971; Williams & Zangwill, 1952). More recently, interest has shifted to comparisons and contrasts of impaired and preserved memory functions in retrograde amnesia (e.g., Butters & Cermak, 1986; Cermak & O’Connor, 1983; Damasio, Eslinger, Damasio, Van Hoesen, & Cornell, 1985; Goldberg, 1987; Zola-Morgan, Cohen, & Squire, 1983). The present case study, too, was focused on dissociations in the patient’s premorbidly acquired knowledge. CASE HISTORY K.C. was born in 1951, the first of five children, and delivered during the seventh month of pregnancy. The postnatal period and infancy was uneventful. Developmental milestones were normal. However, at age 18, he received a blow to the head which resulted in admission to the Montreal Neurological Institute and observation for 3 days. He was discharged on phenytoin and phenobarbitol and remained on these anticonvulsants for 1 year. He had no seizures, but did not reenter school for 1 year. At age 24, he was involved in a traffic accident, without loss of con- sciousness, and sustained a fractured mandible. Although painful, neither of the head injuries appeared to have deleterious effects on K.C.‘s in- tellectual functioning. After graduating from high school, he enrolled in a 3-year course in business administration at a community college and graduated at age 25. In the spring of 1978, aged 27 years, he became employed at BE, an engineering and manufacturing company. His job consisted of two activities: driving a delivery and pick-up truck and doing quality control work. The accident responsible for K.C.‘s present condition occurred October 1981, at age 30. Riding his motorcyle home from work, he went off the road. No other vehicles were involved in the accident. He remained unconscious for approximately 72 hr, when a subdural hematoma was removed from the left cranium. He then became stuporous, but responded to commands for about the next 4-5 days. At approximately the seventh post-traumatic day he appeared to recognize his mother. The patient remained in an intensive care unit for 4 weeks. He was transferred to a rehabilitation hospital 6 weeks after the accident and exhibited a severe right hemiplegia. He was discharged home in July 1982, where he has remained in the care of his parents. PRIMING IN RETROGRADE AMNESIA 5 Neurological examination on December 12, 1986, revealed an alert, cooperative individual who responded appropriately to all questions. The most striking feature was a marked apathy, flattening of affect, and general indifference to his surroundings. Significant neurological signs included: bilateral anosmia, a right homonymous hemianopia with macular sparing (corrected visual acuity 52 on the right and 58 on the left) and bilateral optic disc pallor. The eye movements were full in the horizontal and vertical planes and no nystagmus was evoked. The left pupil measured 6 mm and responded poorly to light and accommodation whereas the right pupil measured 4 mm and responded more briskly to light and accommodation. The lower cranial nerves were intact. In the motor system there was ulnar deviation in the right hand, and in the foot lateral deviation of the great toe with marked restriction of movement of the small bones of the foot. The power was intact in upper and lower limbs and there was slight increase in tone at the elbow but no supinator spasticity. His coordination for fine finger movements and finger-nose testing were intact. There was no tremor or voluntary move- ments noted. Sensation was intact to pinprick, cold, light touch, and position sense. There was no sensory inattention elicited and two-point discrimination was equal on both sides of the body. In the finger tips, the threshold for two-point discrimination was approximately 2-3 mm. He was able to discriminate between fine and coarse sandpaper in both hands, and dermographia was intact bilaterally. Right hyperreflexia was present in upper and lower limbs and the plantar response was extensor on the right. The palmomental reflex was more pronounced on the right and the pout and snout reflexes were brisk. He exhibited a hemiplegic gait. Computerized axial tomography, Fig. 1, and magnetic resonance imaging scans of the head were performed. There is mild cerebral and cortical atrophy as evidenced by enlargement of the sulci, ventricles, and cerebellar folia. There is evidence of contusion in the deep white matter of the left frontal-parietal region, and right parieto-occipital region (magnetic res- onance scan). There is an infarct in the distribution of the left posterior cerebral artery and a large defect in the left frontal-parietal region sub- adjacent to the previous craniotomy. Positon emission tomography was performed and this revealed that glucose utilization was essentially normal in the regions of the left hemisphere which did not exhibit damage as revealed by the CAT-scan. K.C. has been observed and tested at our Unit for Memory Disorders since 1983. He participated in a 2-year longitudinal study of memory and cognitive performance of three groups of patients with memory disorders (Schacter, Harbluk, & McLachlan, 1984), as well as in a number of other experiments. For instance, a brief summary description of his state of 6 TULVING ET AL. FIG. 1. Computerized tomographic scan images of Patient K.C. The right side of the brain is to the reader’s left. PRIMING IN RETROGRADE AMNESIA 7 consciousness has been provided in Tulving (1985b), where he is identified by the code initials N.N. Also, under the code initials C.H. he participated in a study demonstrating amnesic patients’ ability to learn new computer- related vocabulary (Glisky, Schacter, & Tulving, 1986b) and computer programming (Glisky, Schacter, & Tulving, 1986a). For the purposes of the present study, K.C. was seen in four weekly sessions beginning in early October 1986, and continuing through January 1987. Each session typically lasted 24 or 3 hr. In addition, on two occasions we visited with K.C. the site of the BE plant where he had worked between 1978 and 1981, visited K.C.‘s present and previous homes, talked to his family, and interviewed three friends, all co-workers at BE at the time that K.C. worked there. Our knowledge of K.C.‘s past life in general and the 3 years at BE in particular is based on information provided by his parents, his brother, and his three friends and co-workers. CURRENT MENTAL STATUS K.C. is a quiet, polite, and cooperative person. He seldom complains about anything. In response to direct questions he says that his life is good, although he concedes that he has problems with his memory.
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